Back Pain Flashcards
List some of the more common causes of back pain.
Focus on first 5
What are the clinical features of mechanical back pain?
When performing a clinical assessment it is important to differentiate self-limiting disorder of acute mechanical back pain from serious spinal injury
- Most common for people between the ages 20-55
- Associated with bending and lifting
- Exacerbated by activity and relieved with rest
- Usually confined to the lumbar–sacral region, buttock or thigh
- Usually symmetrical
- Does not radiate beyond the knee - indicative of nerve damage
- On examination there may be asymmetric local paraspinal muscle spasm and tenderness, and painful restriction of some, but not all, movements
What is the prognosis for mechanical back pain?
Prognosis is generally good - after 2 days, 30% are better and 90% have recovered by 6 weeks.
10–15% of patients go on to develop chronic back pain that may be difficult to treat
Psychological elements, such as job dissatisfaction, depression and anxiety, are important risk factors for the transition to chronic pain and disability
What are some red flags (history and examinations) that indicate more serious spinal pathology?
History
- Younger than 20, older than 55
- Constant pain, unreleived by rest
- Location - thoracic
- Past history of carcinoma, tuberculosis, HIV, systemic glucocorticoid use, osteoporosis
- Systemic upset, sweats, weight loss
- Major trauma
Examination
- Painful spinal deformity
- Severe/symmetrical spinal deformity
- Saddle anaesthesia (reduced sensation around buttocks)
- Nuerological signs
- Muscle wasting
How does nerve root pain normally present itself?
- Unilateral leg pain that is worse than low back pain
- Pain radiaiton beyond the knee
- Paraesthesia in same distribution
- Nerve root irritation
- Motor, sensory or reflex signs
Prognosis - 50% recover in 6 weeks
What is cauda equina syndrome?
Cauda Equina Syndrome is a SURGICAL EMERGENCY - Nerve compression in the cauda equina
It is usually the result of massive disc herniation, and many nerves can be compressed in the cauda equina.
What are the clinical features for cauda equina syndrome?
- Difficulty in micturition (urinating)
- Loss of anal sphincter tone or faecal incontinence
- Sensory loss - saddle anaesthesia
- Gait Disturbance
- Pain, numbness and weakness affecting one or both legs
What are the differentiating symptoms for each of these conditions - Spinal stenosis, degenerative disc disease, inflammatory back pain and spondylolisthesis
Spinal stenosis - narowing of the spinal canal (mutliple causes - e.g. tumour, OA, RA, etc.) - leg discomfort on walking that is relieved by rest, bending forwards or walking uphill. Patients adopt simian posture (foward lean, slight flexion in the hips and knees)
Degenerative disc disease - common in middle aged adults - bulging or prolapsed disc - nerve root pain with sensory deficit, motor weakness and asymmetrical reflexes
Inflammatory back pain (axial spondyloarthritis - SI joint arthritis) - gradual onset and almost always occurs before the age of 40, associated with morning stiffness and improves with movement
Spondylolisthesis (bones in your spine slip forward) may cause back pain that is typically aggravated by standing and walking
If someone present with lower back pain, what type of investigations are performed?
Investigations not required in patients with acute lower back pain
Those with persistent pain or red flags should undergo further investigation
MRI is the investigation of choice because it can demonstrate spinal stenosis, cord compression or nerve root compression, as well as inflammatory changes in axSpA, malignancy and sepsis.
Plain X-rays can be of value in patients suspected of having vertebral compression fractures, OA and degenerative disc disease
Additional investigations that may be required include routine biochemistry and haematology - rule out infection and tumours
What is the treatment for people with mechanical back pain?
- Education is important in patients with mechanical back pain - emphasise the self-limiting nature of the condition (resolves on its own without long term effects) and the fact that exercise is helpful rather than damaging
- Regular analgesia and/or NSAIDs may be required to improve mobility and facilitate exercise.
- Return to work and normal activity should take place as soon as possible - bed rest is not helpful and will increase the risk of chronic disability
- Referral for physical therapy should be considered if a return to normal activities has not been achieved by 6 weeks.
When is surgery used for low back pain?
Surgery is required in less than 1% of patients with low back pain but may be needed for….
- Progressive spinal stenosis
- Spinal cord compression and in some patients with nerve root compression.
What does the term lumbar spondylosis mean?
Overarching term that describes the lumbar wear and tear of discs and facet joints of the back.
Covers degenerative disc disease and osteoarthritic change in the lumbar spine
What happens during a disc herniation?
Nucleus pulposus may bulge or rupture through the annulus fibrosus, giving rise to pressure on nerve endings in the spinal ligaments, changes in the vertebral joints or pressure on nerve roots.
What are the three main types of lumbar disc herniation? What are they associated with?
What are the clinical features of lumbar disc herniation?
Clinical features
* The onset may be sudden or gradual
- acute lumbar disc herniation is often precipitated by trauma (usually lifting heavy weights while the spine is flexed), genetic factors may also be important.
* Alternatively, repeated episodes of low back pain may precede sciatica by months or years.
* Constant aching pain is felt in the lumbar region and may radiate to the buttock, thigh, calf and foot.
* Pain is exacerbated by coughing or straining but may be relieved by lying flat.
What investigations should be performed on a patient that is thought to have a lumabr disc herniation?
- MRI is the investigation of choice if available, since soft tissues are well imaged.
- Plain X-rays of the lumbar spine are of little value in the diagnosis of disc disease, although they may demonstrate conditions affecting the vertebral body.
- CT can provide helpful images of the disc protrusion and/or narrowing of exit foramina.
What management/treatment is used for lumbar disc herniations?
Some 90% of patients with sciatica recover following conservative treatment with analgesia and early mobilisation; bed rest does not help recovery.
The patient should be instructed in back-strengthening exercises and advised to avoid physical movements likely to strain the lumbar spine
Local anaesthetic or glucocorticoids may be useful if symptoms are due to ligamentous injury or joint dysfunction
Surgery may have to be considered if there is no response to conservative treatment or if progressive neurological deficits develop.
Note - Central disc prolapse with bilateral symptoms and signs and disturbance of sphincter function requires urgent surgical decompression
What is a lumbar canal stenosis? What is the underlying pathophysiology that explains the symptoms?
Lumbar spinal stenosis is a narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs
Symptoms of spinal stenosis are thought to be due to local vascular compromise due to the canal stenosis which results in the nerve roots becoming ischaemic and intolerant of the increased demand that occurs on exercise.
What are the causes of spinal cord compression?
Spinal cord compression is one of the more common neurological emergencies encountered in clinical practice and the usual causes are listed in the image
A space-occupying lesion within the spinal canal may damage nerve tissue either directly by pressure or indirectly by interference with blood supply.
Cause can be found on the…
1. Vertebral level
2. Meninges - three layers of membrane - dura mater, arachnoid mater and pia mater.
3. In spinal cord itself
What are the clinical features of spinal cord compression (general)?
The onset of symptoms of spinal cord compression is usually slow (over weeks) but can be acute as a result of trauma or metastases
What are the different clinical features associated with spinal compression in the…
a) Cervical - above C5
b) Cervical - C5 to T1
c) Thoracic cord
e) Cauda Equina
What is axial spondyloarthropathy? What are the two sub-groups?
Axial spondyloarthropathy includes classical ankylosing spondylitis (AS) as well as axial spondyloarthritis
Axial spondyloarthritis (axSpA) is an inflammatory disease of the axial skeleton associated with significant pain and disability (umbrella term)
Classical ankylosing spondylitis - a type of arthritis characterized by long-term inflammation of the joints of the spine typically where the spine joins the pelvis (SI joint) - otherwise known as radiographic axSpA
What is classical ankylosing spondylitis?
Ankylosing spondylitis (AS) is defined by the presence of sacroiliitis (inflammation of the sacroiliac joint) on X-ray and other structural changes on spine X-rays, which may eventually progress to bony fusion of the spine.
More men are typically effected
Overall prevalence of AS is below 0.5% in most populations.
What are the clinical features for classical ankylosing spondylitis?
Clinical features are the same as in axSpA - inflammatory back pain, early morning stiffness, low back pain radiating, exacerbated by inactivity, fatigue.
AS typically evolves slowly, with fluctuating symptoms of spinal inflammation; ankylosis develops in many patients over a period of many years
Up to 40% of patients also have peripheral musculoskeletal lesions (asymmetrical, affecting entheses of large joints, such as the hips, knees, ankles and shoulders)
Can result in the fusion of spinal joints
Which vertebrae is most commonly effected in lumbar radiculopathy?
L5 radiculopathy is most common - note S1 is also common
Back pain radiating down the lateral aspect of the leg into the foot
Weakness
a) Foot dorsiflexion
b) Toe extension
c) Foot inversion and eversion
What type of diagnosis is performed for a lumbar radiculopathy?
Clinical diagnosis but need to watch-out for other causes or red flags (attached)
David Kluth’s treatment for mechanical back and radiculopathy?
How do osteoporotic vertebral fractures normally present?
Osteoporotic vertebral fractures - can happen acutely or slowly overtime
Most likely in thoracic or lumbar spine
Acute episode associated with sudden onset of back pain, aggrevated when…
a) Coughing
b) Bending
c) Lifting
Pain normally resolves over 4-6 weeks
Leads to loss of height and may cause kyphosis
